Science Supports Circumcision, So Should Skeptics

Author

Deborah Hyde
Deborah Hydehttp://deborahhyde.com/
Deborah Hyde is a folklorist, cultural anthropologist, fellow of the Committee for Skeptical Inquiry. She writes about superstition, religion and belief and is the former editor-in-chief of The Skeptic.

More from this author

Spellbound: Magic, Ritual and Witchcraft

Deborah Hyde reports from the Spellbound: Magic, Ritual and Witchcraft exhibition at the Ashmolean Museum of Art and Archaeology, Oxford.

Do ghosts exist? If not, why do we see them?

  This is the deceptively simple question I ask at the beginning of every episode of the Haunted podcast. The show features ghost stories that...

Naturopath Suing Skeptic Blogger Britt Hermes

Award-winning skeptic blogger Britt Hermes - who turned her back on naturopathic 'medicine' - is the subject of a lawsuit by Arizona naturopath Colleen...

Werewolves

  A werewolf attacks a man Hans Baldung Grien From Die Emeis (1516) Guest Contributor: Deborah Hyde Johann Geiler von Kaisersberg (1445-1510), the ‘Doctor Keisersperg’ of the caption above,...

RIP Hitch

Anthony Burns ruminates on Hitch’s persistent preoccupations, and wonders aloud about that supposed move from left to right “For a lot of people, their first...

Brian Morris Ph.D

Skeptics are generally considered to be intelligent individuals who base their views on hard science, not the misinformation perpetrated by fringe groups with an agenda. It was therefore quite astonishing to read the article on childhood male circumcision by Marianne Baker.1 This biased opinion piece draws its information almost exclusively from blogs and websites of the anti-circumcision lobby rather than evidence in mainstream peer-reviewed medical journals. The present article shows that a true skeptic should dismiss Baker’s claims in the same way as skeptics dismiss the beliefs of those who oppose childhood vaccination, advocates of homeopathy and other questionable ‘alternative’ therapies, climate change deniers, moon landing questioners, religious fanatics and flat-Earth proponents. A gullible person reading anti-circumcision propaganda might be duped. But a skeptic should take care to question the claims and seek reliable evidence.

Evidence-based policy statements

The only evidence-based policy statements are two published in peer-reviewed journals in 2012 by the American Academy of Pediatrics2 and by Fellows of the Royal Australasian College of Physicians (RACP) and other medical bodies on behalf of the Circumcision Foundation of Australia.3 Each report involved an extensive review of the medical literature and based its findings on research of high quality. Each stated that male circumcision provides strong protection against: urinary tract infections (UTIs) that in infancy cause kidney damage; phimosis; paraphimosis; balanoposthitis; foreskin tearing; some heterosexually transmitted infections (STIs) including oncogenic human papillomavirus (HPV), genital herpes (HSV-2), trichomonas, HIV, and genital ulcer disease; thrush; inferior hygiene; penile cancer and possibly prostate cancer. It also protects women against HPV, HSV-2, cervical cancer, bacterial vaginosis, and possibly Chlamydia. Each reported that male circumcision has no adverse effect on sexual function, sensitivity, penile sensation or satisfaction and may enhance the male sexual experience. Adverse effects were uncommon (<1%), virtually all being minor and easily treated. Male circumcision was found to be beneficial, safe and cost-effective, and should optimally be performed in infancy using local anaesthesia. Each recommended that in the interests of public health and individual wellbeing, adequate parental education, and steps to facilitate access and affordability should be encouraged in developed countries.

By contrasting the degree of risk of complications with a tally of each of the benefits it was concluded that over their lifetime up to half of uncircumcised males will suffer a medical condition as a result of retaining their foreskin and that “The ethics of infant MC and childhood vaccination are comparable”.3

Just as for childhood vaccination, no western democracy allows “routine infant circumcision”. Parental consent is required for each, the decision to circumcise being up to the parents. Since “physicians sometimes can be held accountable for harm that results from not telling patients about an available medical treatment or procedure” it has been suggested that parents who, after being advised of the risks and benefits, then decline to have their baby boy circumcised should sign a document in order to protect the attending clinician from litigation should the male go on to develop harmful medical conditions associated with not being circumcised.4

Should circumcision be delayed?

Some of those who accept that male circumcision has important benefits have argued that circumcision should be delayed until the male is old enough to make up his own mind. There are, however, significant flaws in this argument. Infant circumcision cannot be equated with adult circumcision. Delaying circumcision to adolescence or adulthood may evoke unfounded fears of pain, penile damage or reduced sexual pleasure, as well as embarrassment. Time off work or school will be needed, cost is much greater, as are risks of complications. A surgeon may insist on general anaesthesia, healing is slower, and stitches or tissue glue must be used.5 The neonatal period is the optimal time for circumcision because an infant’s low mobility facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually excellent, costs are minimal, and complications are uncommon. Importantly the boy gains the paediatric benefits immediately, and when older enters the sexually active years equipped with substantial protection against additional hazards, including various STIs and penile cancer.5

Protection from urinary tract infections

Neonatal circumcision confers 10-fold protection against UTIs.6 These are excruciatingly painful and common in uncircumcised males, affecting 1 in 50 in infancy,7 1 in 20 by age 7, and over the lifetime 1 in 3.6 Baker is quite naïve in dismissing UTI as a reason for circumcision by saying they are easily treated with antibiotics. Paediatric UTI can lead to significant morbidity,8 including sepsis and death.9 Approximately half of febrile UTI cases in infancy are associated with renal parenchymal disease,10 which exposes them to serious, life-threatening medical conditions later in life.11,12 Unlike the impression Baker conveys, UTI is far from a minor medical problem and costs can be considerable. Apart from the risk of permanent kidney damage, UTI will often necessitate a catheterised urine collection, venipuncture, bacterial culture, lumbar puncture, hospitalization, and intravenous antibiotic administration. Each of these medical interventions can have adverse consequences. Based on conservative estimates from the largest study to date, UTI leads to bacterial infection in the bloodstream in 6.5% of cases, adverse events in 2.8%, and potentially fatal, secondary bacterial meningitis from bacterial dissemination to the central nervous system in 0.3% of affected infants.13 Lumbar puncture for diagnosis of meningitis, even though the safest strategy, is painful and is associated with potential complications.14 Antibiotics do not easily enter the cerebrospinal fluid, so will fail to treat meningitis. With the advent of multi-drug resistant gram-negative Escherichia coli, UTI treatment will increasingly involve intravenous rather than oral antimicrobials.15 Because of ‘superbugs’, UTI may one day become untreatable, leading to fatalities. Thus measures to prevent occurrence of UTI should be seen as paramount. Moreover, treatment of the pain of UTI in babies with the commonly used medication paracetamol is increasingly being questioned based on growing biological and epidemiological evidence linking its use to autism.16 Could the link to vaccination touted by the anti-vaccination lobby, actually be paracetamol use in susceptible infants?

Reduction in sexual function and sensitivity is a myth

The gold standard of epidemiological evidence is the large randomised controlled trial. Two such trials found that by the 2 year-follow-up visit circumcision had had no adverse effect on sexual function, sensation and satisfaction.17,18 In one of the trials most men said sex was better after having been circumcised.18 A meta-analysis, which can evaluate all studies and arrive at an overall finding, determined that circumcision has no detrimental effect on erections, ejaculatory latency, premature ejaculation, sexual desire, orgasm difficulties or pain during intercourse.19 The foreskin, just as other parts of the penis, contains touch receptors, mostly Meissner’s corpuscles. These enable the flaccid penis to sense touch. Sexual sensation is mediated by genital corpuscles. These are absent from the foreskin.20 A survey of men who were asked to rate their penile sensitivity to sexual stimulation found that the underside of the glans was best, followed by the underside of the shaft, upper side of the glans, left and right side of the glans, one or both sides of the penis, and upper side of the penile shaft, whereas of all parts of the penis, the foreskin was rated the least sensitive.21 Research claiming circumcision harms sexual function and sensitivity have been discredited because of serious flaws.22-25

The glans does not undergo an increase in keratinisation (Baker’s “hardening”) after circumcision.26 Therefore her assertion that this “further diminishes feeling” is also incorrect. Speculation that retention of the foreskin allows a gliding movement during intercourse and less friction, if true, would mean an uncircumcised man in effect masturbates within the vagina, rather than experiencing the sensation of his penis sliding against the vaginal wall. Condoms would dampen each of these phenomena. Women report that pain during intercourse is less with circumcised men, and in every other way women find sexual activity to be better with men who are circumcised,27-29 the only exception reported in one survey being ease of eliciting orgasm in the male partner by hand.27

The “natural moisture” that Baker claims is removed by circumcision is in fact smegma, a white film that consists of bacteria, shed skin cells and dirt, with an offensive odour. Baker seems to think it is easy for an uncircumcised male to practice “good hygiene”. Washing requires retraction of the foreskin. But many boys don’t or can’t retract their foreskin until well into their teens, and some men never can, mostly because they have phimosis or severe inflammation of the foreskin. Washing has only a short-term effect. The bacterial odour returns after a few hours and even faster in a hot climate. Following urination some urine will be left on the foreskin. The inner lining of the foreskin is mucosal, so making it sensitive to soap. Even mild soap can cause irritation and redness. Unlike the vagina, the penis does not have a self-cleaning mechanism.

Penile cancer can be “reduced simply by good hygiene” is a myth

While hygiene is desirable, there is scant evidence that it prevents penile cancer. The risk factors for penile cancer are phimosis (12-fold), balanitis (4-fold) and smegma (3-fold).30 Half of penile cancers contain cancer-causing types of human papillomavirus. All of these factors are either more common or found only in uncircumcised men. While penile cancer is uncommon, it is not rare. It is only rare in men who were circumcised in infancy.30 At best, the HPV vaccines might reduce penile cancer by 35%.31 They will have no impact on prostate cancer.

Victorian beliefs

Citing an article by a jazz musician,32 Baker says circumcision was used in Victorian times to treat a wide array of medical conditions that today seem unconnected to circumcision. These ideas of the time seem not to have had widespread currency, however, since circumcision is not mentioned in major texts of the Victorian era that rail against masturbation.33 We should appreciate that in Victorian times syphilis was a devastating, incurable disease. In 1855 circumcision was first reported to be associated with a reduced risk of syphilis.34 At the time, the existence of microorganisms and their role in disease transmission were unknown. But the Victorians did observe an association between sexual activity and syphilis. This may explain why a seemingly logical connection was made by a minority view advocating circumcision to reduce masturbation (a form of sexual activity and thereby linked to syphilis). Research has now shown that circumcision does not reduce masturbation, one large American survey finding in fact that circumcised men enjoy a more varied array of sexual activities.35 Now that sexual transmission of the spirochete bacterium Treponema pallidum by an infected person is known to be the cause of syphilis, the Victorian idea held by a minority seems absurd.

In Britain male circumcision has traditionally been a mark of the upper classes. It is more common in families with higher levels of education, wealth and social standing.33 The Royals are all circumcised. A lack of circumcision showed that a midwife rather than a doctor attended the birth.

The ‘male genital mutilation’ misnomer

Most illogical is the use of the term male genital mutilation” to refer to male circumcision. Baker appears to do so it seems in an attempt to equate the latter with female genital mutilation, with which it has little in common, either anatomically or health-wise. This particular distortion is used by the anti-circumcision movement to further their agenda of deception.

World circumcision rate

In contrast to Baker’s statistics, the World health Organization estimates that at least 30% of males globally are circumcised.36 Art forms from the Paleolithic have revealed that circumcision of males was practiced in Europe 35,000 years ago.37 Since diverse cultures worldwide practice circumcision it seems more logical that it arose in our species prior to the radiation of Homo sapiens out of Africa rather than independently in geographically distant cultures around the globe.33 Given male cultural domination it would be surprising if an intervention would have persisted if it had an adverse effect on sexual pleasure. Science now provides a host of medical reasons why humans circumcise.

Human rights arguments favour male circumcision

Here Baker’s evidential support comes, it seems, from Youtube! This is one Internet tool used by anti-circumcision propagandists, who use ‘doctored’ images, edit in background sounds of babies screaming and unrelated frames, often from bygone days when local anaesthesia was not used. Any surgical procedure might be shocking to a layperson, no matter how safe and simple it is. But virtually all circumcisions have a good cosmetic outcome and confer a lifetime of benefits. Virtually all adverse events are minor, easily and immediately treatable, and resolve completely. Baker correctly states that complications of infant male circumcision are “relatively rare”, but rather than “under 10%”, have been shown in a large meta-analysis to be 1.5%.38 She goes on, however, to refer to the 117 deaths per year in the USA from infant circumcision myth, failing to trace the source of this claim to an article by an opponent of circumcision – Dan Bollinger – who calculated this figure by erroneously assuming that the well-known higher infant mortality in male versus female babies was entirely a result of infant male circumcision. His argument collapses, however, when one examines infant mortality statistics for other countries. Those with low rates of circumcision experience a similar sex difference (see Table 1 in ref39). In reality deaths from circumcision are extremely rare, especially when the circumcision is performed by a competent medical practitioner.

Opponents of childhood male circumcision argue that the practice is a violation of human rights and cite the United Nations Conventions on the Rights of the Child. But in the UN document 44/25 of 20 November 1989 at Article 14(2) is a statement that parties to the agreement “shall respect the rights and duties of the parents and, when applicable legal guardians, to provide direction to the child in the exercise of his or her right in a matter consistent with the evolving capacities of the child”.40 There is no opposition to childhood male circumcision in any UN document. If there had been then it would be astonishing that countries that practice childhood male circumcision would have been signatories.41 But Israel and Middle Eastern countries are signatories. In fact, given the substantive health benefits, ethical arguments favouring childhood male circumcision appear stronger and more logical than ethical arguments against the practice.41-44 Moreover, the AAP’s bioethics policy makes it clear that parents and guardians have a right to make health care decisions on behalf of their children,45 except when these place the child’s health, well-being, or life at significant risk of serious harm.46 Clearly, for infants with no effective capacity, decisions are entirely the duty of the parents. Of course exceptions include failing to act in the interests of children or situations where a medical procedure or withholding a medical procedure causes serious harm, an example being Jehovah’s Witness parents who refuse to allow their ill child to have a life-saving blood transfusion.

It has similarly been argued that “vaccine choice [is] a human rights issue”.47 Yet vaccination is a minor medical procedure, one that most parents choose for their children, and since its benefits far outweigh the risks, the vaccination of children would seem to be an issue analogous to the circumcision of boys.

The circumcision of boys is legal

Baker seems to want to find a jurisdiction that might one day ban medical circumcision of boys. No Government or medical body anywhere has banned childhood male circumcision. An attempt by opponents in San Francisco led to legislation supporting parents right to have a male child circumcised.48 Baker obfuscates when she says “Germany made a controversial ruling against [childhood male circumcision]”. In reality, the hype in the English-language press was that a minor court in the district of Cologne had banned it, when in fact the court ruled that a doctor who circumcised a boy who suffered bleeding was not guilty of a criminal act because the illegality of circumcision is among the “…undecided questions of law which are not unanimously decided in the literature, especially when the legal position as a whole is very unclear”; it went on to say “This is the case here. The question of the lawfulness of circumcisions of boys on the basis of the consent of their parents is answered differently in case law”. Because of the resulting international embarrassment expressed by Chancellor Angela Merckel, the German federal parliament subsequently passed legislation upholding the right of parents to have their sons circumcised.49

HIV

While Baker declines to be drawn on the proven prophylactic benefits of male circumcision against HIV in settings such as sub-Saharan Africa where HIV is an epidemic, it should be noted that like countries that at present have low HIV rates, HIV rates in epidemic countries were once also low. She fails to acknowledge that in the USA most HIV infections are from receptive anal intercourse amongst gay men and from needle sharing amongst intravenous drug users. In the USA, as elsewhere, male circumcision protects against heterosexual acquisition of HIV.39 Any decline in circumcision in developed countries risks an HIV epidemic.39,50 While African countries are dealing with the HIV crisis by circumcising adult males, they recognize that infant male circumcision will be the way of the future because of the expanded array of benefits and the fact that it is not only cheaper and safer, but equips the male with protection before he reaches the sexually active years of his life when barriers may prevent him getting it done.5 Baker seems to think that the lower HIV prevalence in European countries with low circumcision rates than the USA’s high rate of each proves that circumcision is not beneficial, but fails to realize the numerous sociological and epidemiological differences in sexual practices and HIV acquisition between European countries and the USA.39 HIV rates are moreover as just as high in some European countries.

‘Intactivist’ propaganda

Baker praises the Intactivist anti-circumcision network and others like it, such as NORM-UK, with its collection promotion of the mutilating practice of restoration of a pseudo-foreskin (which would then cause them to suffer foreskin-associated health and hygiene problems), and the misleadingly titled group Doctors Opposing Circumcision whose small membership contains nonmedical individuals such as the musician Hodges, who Baker cites. A true skeptic would realize that the anecdotes Baker refers to are from naïve men with sexual problems who have been duped into thinking that their maladies have something to do with their childhood circumcision. In support she cites a study involving men who visited an anti-circumcision website run by one of its authors, Bollinger, but fails to have read the devastating critique of that study,23 which instead of clinical diagnosis of erectile dysfunction, instead surveyed erectile dysfunction drug use, which can be recreational.

To her credit Baker recognised that “the anti-circumcision movement (or Intactivism as it was coined) is rife with other anti-medical-establishment ideas such as anti-vaccination [and] natural fallacies left right and centre”. But despite this connection, Baker fails to recognize that the anti-circumcision movement is firmly within the realm of the same anti-science, alternative fringe propaganda that applies to opponents of childhood vaccination.

Skeptics should indeed be ‘Speaking out’

While acknowledging that “Skeptics are wont to demand data over anecdotes” Baker then says “However, anecdotes may well play a powerful role” and admits to involvement in a website that posts anecdotes from men unhappy about having been circumcised. As a final last gasp she names a few celebrities who she claims are anti-circumcision, saying, curiously, “Unfortunately, celeb support can work wonders for causes, and I certainly won’t pass it up in this case”.

Rather than Baker’s final note to “be skeptical about circumcision”, a true skeptic should reject Baker’s diatribe and be encouraged to examine the medical scientific evidence on this important preventive health issue.

Author

Brian Morris is a Professor in the School of Medical Sciences at the University of Sydney, Australia. His 35 year academic career followed postdoctoral training in the USA, a PhD in Melbourne and BSc(Hons) in Adelaide. He has over 330 academic publications, 50 being on the topic of male circumcision.

References

  1. Baker M: The first cut is the deepest. The Skeptic. 2013(Spring):19-23.
  2. American Academy of Pediatrics. Circumcision policy statement. Task Force on Circumcision. Pediatrics. 2012;130:e756-e785.
  3. Morris BJ, Wodak AD, Mindel A, et al.: Infant male circumcision: An evidence-based policy statement. Open J Prevent Med. 2012;2:79-82.
  4. Brown JL: Medical-legal risks associated with circumcision of newborn males: need for revised consent. AAP News. 2013;34:1.
  5. Morris BJ, Waskett JH, Banerjee J, et al.: A ‘snip’ in time: what is the best age to circumcise? BMC Pediatr. 2012;12(article20):1-15.
  6. Morris BJ, Wiswell TE: Circumcision and lifetime risk of urinary tract infections: A systematic review and meta-analysis. J Urol. 2013:189:2118-2124.
  7. Simon P, Roumeguere T, Noël JC: Human papillomavirus infection in couples with female low-grade intraepithelial cervical lesion. Eur J Obstet Gynecol Reprod Biol. 2010;153:8-11.
  8. Chon CH, Lai FC, Shortliffe LM: Pediatric urinary tract infections. Pediatr Clin North Am. 2001;48:1441-1459.
  9. Schoen EJ: Circumcision for preventing urinary tract infections in boys: North American view. Arch Dis Child. 2005;90:772-773.
  10. Zorc JJ, Kiddoo DA, Shaw KN: Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev. 2005;18:417-422.
  11. Wiswell TE: The prepuce, urinary tract infections, and the consequences. Pediatrics. 2000;105:8602.
  12. Jacobson SH, Eklof O, Eriksson CG, et al.: Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up. Brit Med J. 1989;16:703-706.
  13. Schnadower D, Kuppermann N, Macias CG, et al.: Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics. 2010;126:1074-1083.
  14. Tebruegge M, Pantazidou A, Curtis N: Question 1. How common is co-existing meningitis in infants with urinary tract infection? Arch Dis Child. 2011;96:602-606.
  15. Looke DFM, Thomas Gottlieb T, Jones CA, Paterson DL: Gram-negative resistance: can we combat the coming of a new “Red Plague”? Med J Aust. 2013;198:243-244.
  16. Bauer AZ, Kriebel D: Prenatal and perinatal analgesic exposure and autism: an ecological link. Environ Health. 2013;12:41.
  17. Kigozi G, Watya S, Polis CB, et al.: The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int. 2008;101:65-70.
  18. Krieger JN, Mehta SD, Bailey RC, et al.: Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med. 2008;5:2610-2622.
  19. Tian Y, Wang J, Wazir R, Yue X, Wang K: Effects of circumcision on male sexual functions: a systematic review and meta-analysis.  2013:Asian J Androl (in press doi aja2013.47).
  20. Rhodin JAG. Histology. London: Oxford University Press; 1974.
  21. Schober JM, Meyer-Bahlburg HF, Dolezal C: Self-ratings of genital anatomy, sexual sensitivity and function in men using the ‘Self-Assessment of Genital Anatomy and Sexual Function, Male’ questionnaire. BJU Int. 2009;103:1096-1103.
  22. Waskett JH, Morris BJ: Fine-touch pressure thresholds in the adult penis. (Critique of Sorrells ML, et al. BJU Int 2007;99:864-869). BJU Int. 2007;99:1551-1552.
  23. Morris B, J., Waskett JH: Claims that circumcision increases alexithymia and erectile dysfunction are unfounded. Int J Men’s Health. 2012;11:177-181.
  24. Morris BJ, Waskett JH, Gray RH: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol. 2012;41:310-312.
  25. Morris BJ, Krieger JN, Kigozi G: Male circumcision decreases penile sensitivity as measured in a large cohort. [Critique of Bronselaer et al. BJU Int 2013; 111: 820-827]  BJU Int. 2013:111:E269-E270.
  26. Szabo R, Short RV: How does male circumcision protect against HIV infection? Brit Med J. 2000;320:1592-1594.
  27. Williamson ML, Williamson PS: Women’s preferences for penile circumcision in sexual partners. J Sex Educ Ther. 1988;14:8-12.
  28. Cortés-González JR, Arratia-Maqueo JA, Gómez-Guerra LS: [Does circumcision has an effect on female’s perception of sexual satisfaction?]  (Article in Spanish). Rev Invest Clin. 2008;60:227-230.
  29. Cortés-González JR, Arratia-Maqueo JA, Martínez-Montelongo R, Gómez-Guerra LS: [Does circumcision affect male’s perception of sexual satisfaction?]. [Article in Spanish]. Arch Esp Urol. 2009;62:733-736.
  30. Morris BJ, Gray RH, Castellsague X, et al.: The strong protection afforded by circumcision against cancer of the penis. (Invited Review). Adv Urol. 2011(Article ID 812368):(21 pages).
  31. Morris BJ, Mindel A, Tobian AAR, et al.: Should male circumcision be advocated for genital cancer prevention? Asian Pacific J Cancer Prevent. 2012;13:4839-4842.
  32. Shuttleworth J: Prosecutor asks jury to convict pianist of molesting boys. http://www.nbcbayarea.com/news/local/Prosecutor-Asks-Jury-to-Convict-Pianist-of-Molesting-Boys-147095215.html (last accessed 20 May 2013). NBC Bay Area. 2012.
  33. Cox G, Morris BJ. Why circumcision: From pre-history to the twenty-first century. In: Bolnick D. A., Koyle M. A., Yosha A., eds. Surgical Guide to Circumcision. London: Springer; 2012:243-259.
  34. Hutchinson J: On the influence of circumcision in preventing syphilis. Medical Times and Gazette. 1855;II:542-543.
  35. Laumann EO, Maal CM, Zuckerman EW: Circumcision in the United States. Prevalence, prophyactic effects, and sexual practice. J Am Med Assoc. 1997;277:1052-1057.
  36. WHO and UNAIDS. Male circumcision: global trends and determinants of prevalence, safety and acceptability. (42 pp; 191 refs). Geneva: World Health Organization; 2008. http://whqlibdoc.who.int/publications/2007/9789241596169_eng.pdf
  37. Angulo JC, García-Díez M: Male genital representation in Paleolithic art: erection and circumcision before history. Urology. 2009;74:10-14.
  38. Weiss HA, Larke N, Halperin D, Schenker I: Complications of circumcision in male neonates, infants and children: a systematic review. BMC Urol. 2010;10:2(13 pages).
  39. Morris BJ, Bailey RC, Klausner JD, et al.: A critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries. AIDS Care. 2012:24:1565-1575.
  40. United Nations Convention on the Rights of the Child. 44/25 20 November 1989. Available at: http://www2.ohchr.org/english/law/crc.htm. (Last accessed Feb 8, 2013).
  41. Jacobs AJ: The ethics of circumcision of male infants. Isr Med Assoc J. 2013;15:60-65.
  42. Benatar M, Benatar D: Between prophylaxis and child abuse: the ethics of neonatal male circumcision. Am J Bioeth. 2003;3:35-48.
  43. Benatar D, Benatar M: How not to argue about circumcision. Am J Bioethics. 2003;3:W1-W9.
  44. Clark PA, Eisenman J, Szapor S: Mandatory neonatal male circumcision in Sub-Saharan Africa: Medical and ethical analysis. Med Sci Monit. 2007;12:RA205-RA213.
  45. American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995;95(part 1):314-317.
  46. Diekema DS: Parental refusals of medical treatment: the harm principle as threshold for state intervention. Theor Med Bioeth. 2004;25:243-264.
  47. Morton R. University stands by anti-vaccine student. The Australian, 26 Sep. Available at: http://www.theaustralian.com.au/higher-education/university-stands-by-anti-vaccine-student/story-e6frgcjx-1226481373743. (Last accessed 22 Oct 2012).
  48. California Assembly Bill 768. Male circumcision. http://legiscan.com/CA/text/AB768/id/348729. Available at: http://legiscan.com/CA/text/AB768/id/348729.
  49. DW news-service. Circumcision remains legal in Germany. Available at: http://www.dw.de/circumcision-remains-legal-in-germany/a-16399336 (Latst acessed Feb 7, 2013).
  50. Cooper DA, Wodak AD, Morris BJ: The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust. 2010;193:318-319.

 

##Author Bio ##

 

 

- Advertisement -

Latest articles

Conspiracy theorists, anti-vaxxers and alt-med quackery put our pets in harm’s way

Vet Danny Chambers highlights how the aggressive promotion of alternative therapies to prevent and treat animal diseases has become widespread.

‘Mask Mouth’: A real dental phenomenon, or merely a confection?

Dentist Shaun Sellars looks at recent reports of facemasks causing a new dental phenomenon known as 'mask mouth'.

The Ockham Awards 2020: recognising the best in skepticism, and the worst in pseudoscience

Nominations for the 2020 Ockham Awards are now open, with our annual award for Skeptical Activism and our Rusty Razor award for pseudoscience.

Don’t believe what you think!

What follows is a slightly modified and abbreviated version of the introduction to Professor Edzard Ernst's recently published book, Don't Believe What...

Ethics for Skeptics: why compassion and reason go hand in hand

Philosophy lecturer Aaron Rabinowitz outlines the ethical core of skepticism, and explains why a compassionate understanding of morality must underpin the skeptical worldview.

More like this